1 Tex. Admin. Code § 363.215 - Termination, Reduction, or Denial of Authorization for Prescribed Pediatric Extended Care Center Services
(a) HHSC
terminates authorization for PPECC services when:
(1) the participant is no longer eligible for
the Texas Health Steps Comprehensive Care Program;
(2) the participant no longer meets the
medical necessity criteria for PPECC services;
(3) the PPECC cannot ensure the health and
safety of the participant;
(4) the
participant or the participant's responsible adult refuses to comply with the
plan of care, and compliance is necessary to assure the health and safety of
the participant;
(5) the
participant changes PPECC providers, and the change of notification is
submitted to HHSC in writing with a prior authorization request from the new
PPECC provider; or
(6) the
participant declines to continue receiving PPECC services and chooses to
receive services at home.
(b) Notice to approve, reduce, deny, or
terminate requested PPECC services.
(1) HHSC
notifies the participant and the responsible adult in writing of the approval,
reduction, denial, or termination of PPECC services.
(2) HHSC notifies the provider in writing of
the approval, reduction, denial, or termination of PPECC services.
(3) The effective date of the service
reduction or denial is 30 calendar days after the date on the individual's
notification letter.
(4) HHSC
notifies the individual in writing of the process to appeal the reduction or
denial of services.
(c)
All participants of Medicaid-funded services have the right to appeal actions
or determinations made by HHSC as described in Chapter 357, Subchapter A of
this title (relating to Uniform Fair Hearing Rules).
Notes
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